A 49–year–old T4 paraplegic man presented after being found down in his yard for one day. He was oriented only to self and had several large stage–three decubitus ulcers. His left foot was erythematous, edematous and tender to palpation with red streaking reaching to the thigh. He was febrile with an associated leukocytosis. He was given empiric antibiotics and admitted to hospital. On the first day of hospitalization, he became hypotensive and the blood cultures returned positive for methicillin–resistant staphylococcus aureus (MRSA). He was transferred to the ICU and stepped down a few days later. His blood cultures remained persistently positive despite vancomycin therapy. A TTE revealed no evidence of endocarditits or valvular vegetations. On the fifth hospital day, he again became hypotensive. He began complaining of parasthesia and weakness of his right hand. Because he had a history of multiple back surgeries with placement of internal spinal hardware, a CT myelogram of the spine was ordered and revealed multiple perispinal abscesses causing cord compression syndrome. He was taken emergently to surgery and later transferred to a spinal specialty unit.
Hypotension is frequently encountered by the hospitalist. While sepsis, especially in the found down patient, is usually the presumptive diagnosis, the hospitalist must be cognizant of other etiologies of hypotension. Spinal cord compression secondary to spinal abscess frequently presents with complaints of back pain in conjunction with neurological deficits. Indications of spinal abscess also include nonspecific findings consistent with infection such as fever and lab abnormalities of leukocytosis and an elevated erythrocyte sedimentation rate. Spinal cord compression must be addressed emergently, as the longer it remains untreated, the higher the likelihood that neurological deficits will progress or remain after intervention. MRI is the imaging modality of choice for diagnosis of spinal abscess; however in this particular case CT was chosen as MRI was contraindicated due to the patient’s internal spinal hardware. In addition to the risk to the motor and sensory function, the hospitalist must be cognizant of spinal cord shock, that may accompany severe spinal cord compression. While the MRSA sepsis undoubtedly contributed to our patient’s hypotension, the resolution of the hypotension following the definitive surgical intervention suggests that spinal cord shock was also contributing to his hypotension.
This case also illustrates that the typical symptoms suggestive of cord compression, such as motor deficits and urinary incontinence, are likely to be absent in paraplegic or quadriplegic patients. As these patients are likely to have had surgical procedures previously performed, it is important that the hospitalist maintain a high degree of suspicion for spinal cord absesses in these patients.